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Session 15, February 12, 2019
Andrea Gelzer, M.D., M.S., FACP, Senior Vice President of Medical Affairs
Joe Miller, FHIMSS, Director of Strategy and Innovation
AmeriHealth Caritas Family of Companies
Five Best Practices for Improving Transitions
in Care with Health Information Exchange (HIE)
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Andrea Gelzer, M.D., M.S., FACP
Has no real or apparent conflicts of interest to report.
Joe Miller, FHIMSS
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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Session objectives.
Overview of AmeriHealth Caritas Family of Companies.
Value of HIEs.
Our HIE experience.
Five best practices.
Wrap up.
Questions.
Agenda
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Describe the current state of a health plan’s health information
exchange (HIE) engagement within the context of HIEs
nationally, and assess the opportunities for using data to
improve transitions of care in a multi-stakeholder and
resourced care community.
Plan how to connect to HIEs for optimal value, identifying
essential processes and technologies that will help meet the
goal of improving transitions in care.
Identify key limitations and challenges that can reduce the
value of HIE information, particularly when connecting to more
than one HIE, and how to address them to maximize return
on investment.
Session Objectives
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Has more than 35 years of experience
expanding access to care for members
and striving to maximize value for health
care providers, community organizations,
and government stakeholders.
Is backed by two of the largest and
most well-respected Blue companies,
Independence Health Group and
Blue Cross Blue Shield of Michigan.
Works every day to fine-tune the
future of health care through innovation,
compassion, and an unwavering
dedication to eliminating health disparities.
AmeriHealth Caritas
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AmeriHealth Caritas Markets
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Why Transitions in Care?
It’s a vulnerable time for patients.
Poorly managed transitions associated with increased rates of potentially
avoidable hospitalizations.
Nearly 1 in 5 Medicare patients discharged from hospital are readmitted
within 30 days.
Fewer than 50% of patients see their primary care provider (PCP) within
14 days of hospital discharge.
Sources: Kashiwagi, et al, “Do Timely Outpatient Follow-up Visits Decrease Hospital Readmission Rates?”, American Journal of Medical Quality,
August 2011. “Community-based Care Transitions Program”, https://innovation.cms.gov/initiatives/cctp, accessed January 8, 2019.
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Care transitions offer a good opportunity to intervene.
Successful handling reduces cost.
Failure rates are easily measurable.
Encounter notification data are readily available.
Best practices are applicable to future use cases.
It’s a Place to Prove Value
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Our HIE Journey and
State HIE Connection History
Invested in HIE
infrastructure
and founded
HealthShare
Exchange
(HSX) in
Pennsylvania
Implemented
multi-state
HIE gateway
Integrated
transactions
coming through
our HIE gateway
with back-end
systems
Fully
integrated
to care
management
and provider
applications
Pilot with
Chesapeake
Regional
Information
System for Our
Patients
(CRISP) to
determine value
of leveraging
HIE
District of
Columbia
Southeastern
Pennsylvania
Louisiana
Michigan
Florida Delaware
2014 2015 2016 2017 2018 2019
State HIE connections
Central
Pennsylvania
Implement
FHIR API
pilot
Expand direct
secure
messaging
capabilities
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HIE at a Glance
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State/regional HIEs exchanging
data with our health plans
1,641
Hospitals sending data
to our plans via HIE
1.3M
Members in plans exchanging
information with HIEs
275,009
Continuity of Care Documents
(CCDs) received through HIEs
3.8M
Admission, discharge, and transfer
(ADT) encounter notification alerts
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Collaboration With State HIEs
Plan
HIE
Transactions
(August 2017
August 2018)
AmeriHealth Caritas Louisiana
Louisiana Health Information
Exchange (
LaHIE)
100,379
Keystone First and
Keystone First VIP Choice
HealthShare
Exchange (HSX)
778,996
Prestige Health Choice
Florida HIE Services
(FL HIE)
374,035
AmeriHealth Caritas District
of Columbia
Chesapeake
Regional Information
System for Our Patients (
CRISP)
181,139
AmeriHealth Caritas VIP Choice and
Blue Cross Complete of Michigan
Michigan
Health Information
Network (
MiHIN) Shared Services
981,024
AmeriHealth Caritas Delaware
Delaware
Health Information
Network (D
HIN)
5,400*
* Implemented 2018
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AmeriHealth Caritas HIE Model
1. Participating facilities send ADT alerts and CCDs to AmeriHealth
Caritas via the HIE in real time or near real time (within 24 hours).
2. Our HIE gateway validates the member and applies rules and
predictive modeling.
3. Alert information is routed into the workflow of AmeriHealth Caritas
care managers and providers.
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Five Best Practices
Obtaining and using HIE data
in near real time
Real-time data
Using clinical markers to hone
in on critical cases
Predictive analytics
Integrating the information
with back-end processes
Back-end integration
Enriching the data to see the
whole person needs
Enrich data
Closing the loop through
bi-directional exchange
Bi-directional exchange
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Best Practice 1:
Build for Real-Time Data
Provides access to the right information, for the right person,
at the right time.
Enables timely patient follow-up.
Enables physicians to make better decisions.
HIEs with real-time APIs
HealthShare Exchange (ADTs and CCDs).
Michigan Health Information Network (ADTs and CCDs).
Delaware Health Information Network (ADTs).
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Getting To Real Time Data
Hospital
discharge
HIE receives HIE sends Lapsed time
Best case
Monday
5:46 a.m.
Monday
5:47 a.m.
Monday
6:00 a.m.
14 minutes
Average
Thursday
3:59 a.m.
Thursday
4:15 a.m.
Thursday
6:17 a.m.
2 hours,
18 minutes
Worse case
Tuesday
6:59 a.m.
Wednesday
4:45 a.m.
Thursday
5:00 a.m.
45 hours,
59 minutes
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The Trends We’re Seeing
74 percent of inpatient discharge transactions and 62 percent of
emergency discharge transactions were transmitted from the point of
service to the HIE and then to AmeriHealth Caritas within four hours.
A few outliers were observed where there was a latency in the timing
of the facility sending data to the HIE.
* Dataset uses a representative sample for one HIE for a two-week period in October to November 2018.
0 500 1000 1500 2000 2500 3000 3500 4000 4500
< 4 hrs
4 -12 hrs
12- 24hrs
> 24hrs
< 4 hrs 4 -12 hrs 12- 24hrs > 24hrs
Inpatient
1365 59 510
Emergency
4040 658 439 2445
Real-time ADT data
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Build for APIs for data exchange.
Remove latency at all steps.
Set expectations for real time with HIEs and facilities.
Monitor continuously to identify problems.
Create a flexible HIE “gateway” that can connect to multiple partners.
Challenges: Some facilities and HIEs do not provide real-time exchange,
but rather a daily batch exchange.
Best Practice 1 Guidance
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Volume of transactions is enormous.
Not all discharges are created equal.
Data within the ADT transaction is limited, and facilities vary in how much
information they send. (See below sample from an actual report.)
Best Practice 2:
Apply Predictive Analytics Filters
Hospital
Admit reason Diagnosis
1
GENERAL WEAKNESS, chest pain
(No diagnosis provided)
1
fever, fever unspecified R50.9 FEVER, UNSPECIFIED
2 (No admit reason provided) (No diagnosis provided)
Information from three unique ADT messages for ER visits
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Finding the Needle in the Haystack
Integrated into care
management workflow
Meeting high-risk criteriaHIE ADT alerts
* Aggregated data are representative for July 2018.
Analytic risk stratification predictive models that use various parameters
(e.g., demographics or gaps in care) are applied to member data for
targeting members in need of care.
Targeted members’ ADT data is then integrated into the back-end
processes for effective care coordination.
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Work with clinical staff to select key clinical markers that can be used
to stratify the alerts to identify the most important ones.
Obtain data and integrate into the HIE alert receipt process.
Refine markers as appropriate.
Challenge: Clinical markers for providers may be different than for
care managers.
Best Practice 2 Guidance
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Care managers are the primary users of HIE information
within the payer organization.
Initially, distributing HIE data on reports is adequate.
Eventually, busy care managers will require HIE information
in their workflow.
Best Practice 3:
Integrate with Workflow
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Integration with
Back-End Processes
Care
management
ADT data is integrated
into care management
application based on
pre-defined workflow
rules. This allows care
managers to:
Create event
records and
authorizations.
Update discharge
information.
Close inpatient
cases.
Clinical data
repository
Store ADT
information in
clinical repository.
Integrate ADT
information with
member’s clinical
history data for
enriched reporting.
HEDIS
Key CCD data is
parsed and used
to support HEDIS
measures where
appropriate.
Vital signs are
particularly valuable.
Provider portal
ADT data is
integrated into
provider portal
applications based
on pre-defined
rules.
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Tight integration with care management system using standard
worklists and other triggers is optimal.
HIE data should also be integrated into the broader analytics
environment of the organization.
Build in method to measure care manager follow-up and
feedback loop to management.
Challenge: Finding the balance of volume versus the value for
alerts to care managers and providers.
Best Practice 3 Guidance
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Data in ADT transaction is very limited (see below).
CCD, when received, provides a limited snapshot of the
member’s condition.
Presenting information from other sources is needed for an
adequate understanding to facilitate the transition in care for
the care manager and provider.
Best Practice 4: Enrich Data
for Whole-Person Needs
Hospital
Admit reason Diagnosis
1
GENERAL WEAKNESS, chest pain
(No diagnosis provided)
1
fever, fever unspecified R50.9 FEVER, UNSPECIFIED
2
(No admit reason provided) (No diagnosis provided)
Information from three unique ADT messages for ER visits
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Member data enriched by
aggregating and combining
data from different sources.
Provides a comprehensive
360° view of the member’s
information.
Fulfills whole-person
needs.
Clinical
conditions
Social
determinants
Observations
Tests and
services
Office visits
ImagingLab
Data Enrichment for
Whole-Person Needs
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Clinical Summary Provides
Full View
* Sample member data
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Offer the care team a summary of the member’s clinical
history that can be easily used to support the transition.
Ensure data crosses all care sites, including the most recent
facility encounter.
Provide behavioral health and social determinants
information, which can heavily factor into the transition.
Challenge: Integrating all data sources.
Best Practice 4 Guidance
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Best Practice 5:
Multi-Directional Data Exchange
HIEs tend to be uni-directional.
Provider practices and post-acute care providers are often
the last to become connected, but they are the most
important recipients of information.
Health plans need to encourage partners to connect to
existing channels and, where these are inadequate,
provide information through their own channels.
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Typical and Ideal
Information Exchange
Facility HIE Plan
Primary
care
Post-
acute
Specialist
Current experience
Strong Somewhat Weak
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HIE
Payer Portal Provider
HIE
Payer
Electronic
health
record
Provider
Optimal
Plan Options for Sharing
Relevant Information
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Identify the gaps in HIE coverage, with key organizations
involved in the care team.
Advocate for improvement in HIE coverage to fill gaps.
Look at existing or new plan capabilities to share data such
as portals, direct, and Fast Healthcare Interoperability
Resources (FHIR).
Challenge: Integrating data into the care team provider’s
electronic health record.
Best Practice 5 Guidance
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Benefits and Challenges
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Deliver the right information, on the right patient, to the
right provider, at the right time.
Best practice
Right
information
Right
patient
Right care
manager
provider
Right time
1.
Real-time delivery
2.
Analytics filters
3.
Integrated with
the back end
4.
Comprehensive
information
5.
Multi-directional
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Benefits of HIE: Aligned to Triple-Aim Goals
Improved health outcomes
Effective coordination of care between providers.
Integration of physical and behavioral health care
into a care plan.
Better care
360° view of member health.
Reduction in missed or delayed diagnoses.
Reduction in adverse events.
Improved health monitoring and reporting.
Reduced utilization costs
Reduction in readmissions.
Reduction in the frequency of ER visits.
Prevention of duplicative or repeat tests
(e.g., lab work and diagnostics).
Reduction in the length of hospital stays.
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Questions?
Contact us.
Andrea Gelzer, M.D., M.S., FACP
agelzer@amerihealthcaritas.com
Joe Miller, FHIMSS
jmiller@amerihealthcaritas.com